- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41.16 / $41.16 / $41.16
| Facility | | $41.16 | $41.16 | $41.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41.16 / $41.16 / $41.16
| Facility | | $41.16 | $41.16 | $41.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.05 / $9.05 / $9.05
| Professional | | $9.05 | $9.05 | $9.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12.88 / $12.88 / $12.88
| Professional | | $12.88 | $12.88 | $12.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.96 / $10.86 / $12.67
| Professional | | $9.96 | $10.86 | $12.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.05 / $10.58 / $13.58
| Professional | | $9.05 | $10.58 | $13.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.78 / $8.11 / $14.03
| Professional | | $2.78 | $8.11 | $14.03 |